1. health and fitness
2. therapy

Review Article
Identify the Endodontic Treatment Modalities
Paul A. Rosenberg, DDS,* William G. Schindler, DDS, MS,† Keith V. Krell, DDS, MS, MA,‡
M. Lamar Hicks, DDS, MS,§ and Stephen B. Davis, DDSk
Abstract
Introduction: This paper sought to determine the levels
of evidence associated with treatment for specific diagnostic categories and the prognosis of treatment. Materials and Methods: A review of the literature was
conducted using MEDLINE, PubMed, Google Scholar
and the Cochrane Database. The Journal of
Endodontics, International Journal of
Endodontics, Oral Surgery, Oral Medicine,
Oral Pathology, Oral Radiology and Endodontology, Endodontic Topics, and Dental Traumatology were also searched. The bibliographies of
relevant articles were manually searched. Conclusion:
The review found a low level of evidence to assess clinical treatment modalities. The development of higher
levels of evidence to facilitate the selection of appropriate treatment modalities for each diagnostic category
is recommended. (J Endod 2009;35:1675–1694)
Key Words
Gaps in knowledge, levels of evidence, treatment
modalities
From the *Department of Endodontics, New York University,
New York, New York; †Department of Endodontics, University of
Texas Health Science Center at San Antonio, San Antonio, Texas;
‡
Department of Endodontics, University of lowa, West Des
Moines, lowa; §Department of Endodontics, Operative Dentistry,
and Prosthodontics, University of Maryland, Rockville, Maryland;
and kV.A. Medical Center, Long Beach, California.
We wish to acknowledge the valuable contributions to this
manuscript made by Dr. Jared C. Frisbie-Teel, former Post Graduate Student, Advanced Education Program in Endodontics,
New York University, College of Dentistry, New York, New
York.
Address requests for reprints to Dr. Paul A. Rosenberg,
Department of Endodontics, New York University college of
Dentistry, 345 East 24th Street, New York, NY 10010. E-mail
address: [email protected].
0099-2399/$0 - see front matter
Copyright ª 2009 American Association of Endodontists.
doi:10.1016/j.joen.2009.09.027
Executive Summary
T
he committee sought to determine the levels of evidence associated with treatment
for specific diagnostic categories and the prognosis of treatment. Each subquestion
was assigned to individual committee members in an effort to provide a broad response
to the question. The committee also worked to determine what gaps in knowledge exist
in order to identify optimal treatment modalities for different diagnostic categories. The
gaps identified could point to specific recommendations for future research. The resulting knowledge would bring us closer to improved evidence-based care, which has been
described as the conscientious, explicit, and judicious use of current best evidence in
making decisions about the care of individual patients.
Ng et al (1) have commented that the quality of evidence for treatment factors
affecting primary root canal treatment outcome is suboptimal and that there is substantial
variation in the study designs. It would be desirable to standardize aspects of study design,
including diagnostic terminology, data recording, operative procedures, and outcome
data in future outcome studies. It is essential that we develop higher levels of evidence
to facilitate the selection of appropriate treatment modalities for each diagnostic category.
Methodology
Committee members used the same basic methodology in gathering data in order
to respond to their subquestions. An extensive search of the literature relevant to each
subquestion was conducted electronically using MEDLINE, PubMed, Google Scholar,
and the Cochrane Database. The Journal of Endodontics, International Journal of
Endodontics, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, Endodontic Topics, and Dental Traumatology were also searched. The
bibliographies of relevant articles were manually searched. The committee, using the
Oxford Centre for Evidence-Based Medicine (CEBM) levels of evidence (May 2001),
assigned a level to each paper (2). Responses to subquestions 1, 4, 5, and 6 were
written in narrative form, whereas subquestions 2 and 3 used spreadsheet formats.
Results
As an overview, the committee concluded that there was an inadequate high level of
evidence available for the determination of appropriate treatment with optimum
outcome for each diagnostic category. This was caused in part by substantial variation
in study design. It was noted that reported success rates had not improved over the last 4
or 5 decades (1). Specific gaps in knowledge are included in the response.
Recommendations
The committee recommends standardization of diagnostic terminology, study
design, data recording, and other aspects of outcome studies. The available information
is marked by a lack of standardization among the studies. Specific recommendations
are made in the response in section 4.E. Friedman (3) has commented that an ‘‘undiscerning review of all the existing studies can be ineffective and even misleading.’’
The Committee has used the following American Board of Endodontics’ Pulpal and
Periapical Definitions (4):
Pulpal
Normal pulp. A clinical diagnostic category in which the pulp is symptom free and
normally responsive to vitality testing.
JOE — Volume 35, Number 12, December 2009
Endodontic Treatment Modalities
1675
Review Article
Reversible pulpitis. A clinical diagnosis based on subjective and
objective findings indicating that the inflammation should resolve and
the pulp return to normal.
Irreversible pulpitis. A clinical diagnosis based on subjective and
objective findings indicating that the vital inflamed pulp is incapable of
healing.
Additional Descriptions
Symptomatic. Lingering thermal pain, spontaneous pain, referred
pain.
Asymptomatic. No clinical symptoms, but inflammation produced
by caries, caries excavation, trauma, and so on.
Pulp necrosis. A clinical diagnostic category indicating death of the
dental pulp. The pulp is nonresponsive to vitality testing.
Previously treated. A clinical diagnostic category indicating that
the tooth has been endodontically treated and the canals are obturated
with various filling materials other that intracanal medicaments.
Previously initiated therapy. A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic
therapy (eg, pulpotomy or pulpectomy).
Apical (Periapical)
Normal apical tissues. Teeth with normal periradicular tissues
that will not be abnormally sensitive to percussion or palpation testing.
The lamina dura surrounding the root is intact and the periodontal ligament space in uniform.
Symptomatic apical periodontitis. Inflammation, usually of
the apical periodontium, producing clinical symptoms, including
painful response to biting and percussion. It may or may not be associated with an apical radiolucent area.
Asymptomatic apical periodontitis. Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical
radiolucent area, and does not produce clinical symptoms.
Acute apical abscess. An inflammatory reaction to pulpal infection and necrosis characterized by pain onset, spontaneous pain,
tenderness of the tooth to pressure, pus formation and swelling of associated tissues.
Chronic apical abscess. An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort,
and the intermittent discharge of pus through an associated sinus tract.
Subquestion #1: Which Subjective and
Objective Data Are Needed to Predict
the Outcomes of Various Treatment
Modalities?
Literature Review
The literature reviewed included clinical studies that investigated
the outcome of primary root canal treatment. A search was conducted
electronically (MEDLINE, PubMed, Google Scholar, Cochrane Database) and by manually searching the following journals: Journal of
Endodontics, International Endodontic Journal, Oral Surgery,
Oral Medicine, Oral Pathology, Oral Radiology and Endodontology,
Dental Traumatology, Endodontic Topics and bibliographies of relevant articles. The inclusion criteria were:
Assessment of the outcomes of primary root canal treatment
Sample size stated
At least a 6-month, postoperative assessment
Success criteria clearly stated
1676
Rosenberg et al.
Overall success rates determined
These rather modest inclusion criteria were utilized at the outset to
gather a broad base of information in order to determine the level of
existing knowledge and identify gaps to be addressed. Our response
is directed at evaluating the current level of knowledge using the Oxford
CEBM level of evidence, prioritizing questions that should be addressed
and planning for future studies.
Most studies reviewed were prospective cohort or retrospective
studies. The levels of evidence they provide are levels 2a or 2b based
on the criteria provided by the Oxford CEBM. A review of the literature
clearly shows that there is a lack of randomized, controlled trials that
can be used by a clinician to predictably select clinical treatment modalities that are likely to provide the best outcome. Because of that, there is
a need to synthesize an objective overview of the literature based on
available evidence.
There are nine published systematic reviews that address the
outcomes of primary endodontic treatment. They have used different
approaches in the synthesis of information from the literature. Basmadjian-Charles et al (5) and Paik et al (6) used a systematic approach for
literature search but a traditional approach for evaluating the variables
impacting on the success and failure of the root canal retreatment. Two
other reviews calculated the weighted-average success rates by each
factor under investigation (7, 8). Neiderman and Theodosopoulou
(9) estimated the number of cases needed to treat when comparing
two types of treatments. Three reviews (Lewsey et al [10], Kojima
et al [11], and Sathorn et al [12]) estimated the size of the effect of individual factors that included presence of preoperative pulpal and periapical status, apical extent of root filling, and number of treatment
visits using meta-analysis.
Recent reviews of treatment outcomes were completed by Ng et al
(1, 13) and Friedman (14). They considered the influence of clinical
factors on the outcome of primary root canal treatment. In Ng’s
work, 119 articles were identified; 63 studies published from 1922
to 2002 were selected for review. Six were randomized trials, seven
were cohort studies, and 48 were retrospective studies. Twenty-four
factors (patient and operative) had been investigated in various combinations in the studies reviewed. The influence of preoperative pulpal
and periapical status of the teeth on treatment outcome were most
frequently explored, but the influence of treatment technique was
poorly investigated.
Ng et al’s systematic review (1) reported that success rates had not
improved over the last 4 or 5 decades. The quality of evidence for treatment factors affecting primary root canal treatment outcome was found
to be suboptimal, and there was substantial variation in the study
designs. It was concluded that it would be desirable to standardize
aspects of study design, data recording, and presentation format of
outcome data in future outcome studies (1).
Four conditions (preoperative absence of periapical radiolucency, root filling with no voids, root filling extending to within 2
mm of the radiographic apex, and satisfactory coronal restoration)
were found to significantly improve the outcome of primary root
canal treatment.
Friedman reviewed 479 references out of which he identified
22 selected studies concerning initial nonsurgical root canal treatment as well as six studies pertaining to nonsurgical retreatment,
six studies for surgical treatment, and nine for intentional replantation (14). Friedman makes the point that well-designed cohort
studies may be preferred over randomized, controlled studies
when considering prognosis, whereas randomized, controlled
studies are preferred when comparing the benefits of one procedure
over another (3).
JOE — Volume 35, Number 12, December 2009
Review Article
Recommendation Position Based on Literature/Levels of
Evidence
Based on a review of the literature/levels of evidence, it was
concluded that there is a deficiency of high-level evidence for determining treatment factors effect on primary root canal treatment
outcome. Randomized, controlled trials and high-quality prospective
cohort outcome studies using standardized methodologies should be
encouraged.
The following items represent existing gaps in our knowledge concerning optimal treatment modalities for different diagnostic categories:
The significance of tooth type and number of roots
The significance of demographic factors (eg, age, sex, and influence
of systemic disease)
Influence of smoking
Influence of different types of periodontal disease on endodontic
outcome
Influence of intraoperative procedures
The importance of bacteriologic culturing using modern technology
Protocol and prognosis for regenerative endodontic procedures
Predictability of intentional replantation
Significance of restoration
Appropriate recall period
Appropriate standardized criteria and terminology for determining
outcome
Rationale for Stated Position
A review of the literature shows a lack of evidence-based studies
at the Oxford Center level 1a, the highest level of evidence. The influence of preoperative pulpal and periapical status of teeth on treatment
outcomes were most frequently explored, but the influence of treatment technique and demographic factors has been inadequately
assessed.
Subquestion #1 References
1. Ng Y-L, Mann V, Rahbaran SR, et al. Outcome of primary root
canal treatment: systematic review of the literature—part 1. Effects of
study characteristics of probability of success. Int Endod J
2007;40:921–39.
2. Centre for Evidence-Based Medicine. Available at: www.cebm.
net/index.aspx?o=1025. Accessed March 12, 2008.
3. Friedman S. Prognosis of initial endodontic therapy. Endod
Topics 2002;2:59–88.
4. American Board of Endodontics. Available at: http://www.aae.
org/certboard/currentnews/. Accessed March 12, 2008.
5. Basmadjian-Charles CL, Farge P, Bourgeouis DM, et al. Factors
influencing the long-term results of endodontic treatment: a review of
the literature. Int Dent J 2002;52:81–6.
6. Paik S, Sechrist C, Torabinejad M. Levels of evidence for the
outcome of endodontic retreatment. J Endod 2004;30:745–50.
7. Hepworth MJ, Friedman S. Treatment outcome of surgical and
non-surgical management of endodontic failures. J Can Dent Assoc
1997;63:364–71.
8. Peterson J, Gutmann JL. The outcome of endodontic re-surgery:
a systematic review. Int Endod J 2001;34:169–75.
9. Neiderman R, Theodosopoulou JN. A systematic review of in vivo
retrograde obturation materials. Int Endod J 2003;36:577–85.
10. Lewsey JD, Gilthorpe MS, Gulabivala K. An introduction to
meta-analysis within the framework of multilevel modeling using the
probability of success of root canal treatment as an illustration. Community Dent Health. 2001;18:131–7.
JOE — Volume 35, Number 12, December 2009
11. Kojima K, Iramoto K, Nagamatsu K, et al. Success rate of
endodontic treatment of teeth with vital and nonvital pulps. A metaanalysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2004;97:95–9.
12. Sathorn C, Parashos P, Messer HH. Effectiveness of singleversus multiple-visit endodontic treatment of teeth with apical periodontitis: a systematic review and meta-analysis. Int Endod J
2005;38:347–55.
13. Ng Y-L, Mann V, Rahbaran SR, et al. Outcome of primary root
canal treatment: Systematic review of the literature – Part 2. Int Endod J
2008;41:6–31.
14. Friedman S. Expected outcomes in the prevention and treatment of apical periodontitis. In: Ørstavik, D, Pitt Ford TR, editors. Essential Endodontology. 2nd ed. Ames, IA: Blackwell 2008;408–69.
Subquestion #1 Supplementary References
Bender IB, Rossman LE. Intentional replantation of endodontically
treated teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1993;76:623–30.
Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral
trioxide aggregate: an observational study. J Am Dent Assoc
2008;139:305–15.
Chugal N, Clive J, Spa˚ngberg L. A prognostic model for assessment
of the outcome of endodontic treatment: Effect of biologic and diagnostic variables. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2001;91:342–52.
Cotti I, Mereu M, Lusso D. Regenerative treatment of an immature,
traumatized tooth with apical periodontitis: report of a case. J Endod
2008;34:611–6.
Dugas N, Lawrence H, Teplitsky P, et al. Quality of life and satisfaction outcomes of endodontic treatment. J Endod 2002;28:819–27.
Engstrom B, Hard AF, Segerstad L, et al. Correlation of positive
cultures with the prognosis for root canal treatment. Odontol Revy
1964;15:257–70.
Farzaneh M, Abitol S, Lawrence HP, et al. Treatment outcome in
endodontics: the Toronto Study—phase II: Initial treatment. J Endod
2004;30:302–9.
Farzaneh M, Abitbol S, Friedman S. Treatment outcome in
endodontics: the Toronto study. Phases I and II: orthograde retreatment. J Endod 2004;30:627–33.
Friedman S, Abitol S, Lawrence HP. Treatment outcomes in
endodontics: the Toronto Study—phase I: Initial treatment. J Endod
2003;29:787–93.
Fouad A, Burleson J. The effect of diabetes mellitus on endodontic
treatment outcome: data from an electronic patient record. J Am Dent
Assoc 2003;134:43–51.
Heling I, Gorfil C, Slutzky H, et al. Endodontic failure caused by
inadequate restorative procedures: review and treatment recommendations. J Prosthet Dent 2002;87:674–8.
Keller U. A new method of tooth replantation and auto-transplantation: aluminum oxide ceramic for extraoral retrograde filling. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 1990;70:341–4.
Kerekes K, Tronstad L. Long-term results of endodontic treatment
performed with a standardized technique. J Endod 1979;5:83–90.
Kim MY, Lin JL, White R, et al. Benchmarking the endodontic literature on MEDLINE. J Endod 2001;27:470–3.
Kvist T, Reit C. Results of endodontic retreatment: a randomized
clinical study comparing surgical and nonsurgical procedures. J Endod
1999;25:814–7.
Lindeboom JA, Frenken JW, Kroon FH, et al. A comparative
prospective randomized clinical study of MTA and IRM as root-end
Endodontic Treatment Modalities
1677
Review Article
filling materials in single-rooted teeth in endodontic surgery. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2005;100:495–500.
Marending M, Peters OA, Zehnder M. Factors affecting the
outcome of orthograde root canal therapy in a general dental hospital
practice. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2005;99:119–24.
Marquis VL, Dao TT, Farzaneh M, et al. Treatment outcomes in
endodontics: the Toronto Study—phase III: initial treatment. J Endod
2006;32:299–306.
Molven O, Halse A, Fristad I, et al. Periapical changes following
root-canal treatment observed 20-27 years postoperatively. Int Endod
J 2002; 35:784–90.
Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative
endodontics: a review of current status and a call for action. J Endod
2007;33:377–90.
Ørstavik D, Qvist V, Stoltze K. A multivariate analysis of the outcome
of endodontic treatment. Eur J Oral Sci 2004;112:224–30.
Ørstavik D, Kerekes K, Eriksen H. Clinical performance of three
endodontic sealers. Endod Dent Traumatol 1987;3:178–86.
Ørstavik D, Kerekes K, Eriksen H. The periapical index: a scoring
system for radiographic assessment of apical periodontitis. Endod Dent
Traumatol 1986;2:20–34.
Penesis VA, Fitzgerald PI, Fayad MI, et al. Outcome of one-visit and
two-visit endodontic treatment of necrotic teeth with apical periodontitis: a randomized controlled trial with one-year evaluation. J Endod
2008;34:252–6.
Peters LB, Wesselink PR. Periapical healing of endodontically
treated teeth in one and two visits obturated in the presence or absence
of detectable microorganisms. Int Endod J 2002;35:660–7.
Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large
patient population in the U.S.A.: An epidemiological study. J Endod
2004;30:846–50.
Sjogren U, Hagglund B, Sundquist G, et al. Factors affecting the
long-term results of endodontic treatment. J Endod 1990;16:498–504.
Sjogren U, Figdor D, Persson S, et al. Influence of infection at the
time of root filling on the outcome of endodontic treatment of teeth with
apical periodontitis. Int Endod J 1997;30:297–306.
Strindberg LZ. The dependence of the results of pulp therapy on
certain factors. An analytic study based on radiographic and clinical
follow-up examination. Acta Odontol Scand 1956;14:21.
Torabinejad M, Bahjri K. Essential elements of evidenced-based
endodontics: Steps involved in conducting clinical research. J Endod
2005;31:563–9.
Torabinejad M, Kutsenko D, Machnick TK, et al. Levels of evidence
for the outcome of non-surgical endodontic treatment. J Endod
2005;31:637–46.
von Arx T, Jensen SS, Hanni S. Clinical and radiographic assessment of various predictors for healing outcome 1 year after periapical
surgery. J Endod 2007;33:123–8.
Wang N, Knight K, Dao T, et al. Treatment outcome in endodontics—the Toronto study: phases I and II: apical surgery. J Endod
2004;30:751–-61.
Zuolo ML, Ferreira MOF, Gutmann JL. Prognosis in periradicular
surgery: a clinical prospective study. Int Endod J 2000;33:91–8.
Subquestion #2: What Are the Appropriate
Treatments for Each of the Pulpal
Diagnostic Categories?
Although recognizing it is the combination of pulpal and periapical
diagnoses that guide the practitioner towards appropriate treatment, for
the purpose of this article, the treatment of pulpal and periapical diag1678
Rosenberg et al.
nostic categories will be addressed independently. Endodontic therapy
applicable to each of six pulpal diagnoses is categorized in Tables 1
through 6.
Subquestion #3: What Are the Appropriate
Treatments for Each of the Periapical
Diagnostic Categories?
Using the American Board of Endodontics definitions for periapical pathosis, treatment modalities for periapical diagnoses have been
identified. The related literature has been assessed using the Oxford
Centre CEBM for their levels of evidence. It is important to recognize
that the selection of appropriate treatment is accomplished not only
by determining the pulpal and periapical diagnosis but also by reviewing
other treatment factors as well.
In Table 7, there is significantly more overlap in the treatment
modalities for periapical diagnostic categories than in the pulpal diagnostic categories. There is also an overlap of literature associated with
different treatments. Because the overlap of literature is relative to more
than one treatment modality, the citations have been segregated based
on higher and lower levels of evidence. Articles representing a higher
level of evidence are placed adjacent to treatment modalities and appropriately color coded. Articles with lower levels of evidence are found in
the reference list.
Subquestion #3 Supplementary References
Bystrom A, Happonen RP, Sjogren U, et al. Healing of periapical
lesions of pulpless teeth after endodontic treatment with controlled
asepsis. Endod Dent Traumatol 1987;3:58–63.
Chong BS, Pitt Ford TR, Hudson MB. A prospective clinical study of
mineral trioxide aggregate and IRM when used as root-end filling materials in endodontic surgery. Int Endod J 2003;36:520–6.
Engstrom B, Hard af Segerstad L, Weintraub A, et al. Correlation of
positive cultures with the prognosis of root canal treatment. Odontol
Revy 1964;16:192–203.
Forssell H, Tammisalo T, Forssell K. A follow-up study of apicectomized teeth. Proceedings of the Finnish Dental Society 1988;84:85–93.
Hoskinson SE, Ng YL, Hoskinson AE, et al. A retrospective
comparison of outcome of root canal treatment using two different
protocols. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2002;93:705–15.
Huumonen S, Lenander-Lumikari M, Sigurdsson A, et al. Healing
of apical periodontitis after endodontic treatment: a comparison
between a silicone-based and a zinc oxide-eugenol-based sealer. Int Endod J 2003;36:296–301.
Jensen SS, Nattestad A, Egdo P, et al. A prospective, randomized,
comparative clinical study of resin composite and glass ionomer cement
for retrograde root filling. Clin Oral Investig 2002;6:236–43.
Kerekes K, Tronstad L. Long-term results of endodontic treatment
performed with a standardized technique. J Endod 1979;5:83–90.
Kvist T, Reit C. Results of endodontic retreatment: a randomized
clinical study comparing surgical and nonsurgical procedures. J Endod
1999;25:814–7.
Marending M, Peters OA, Zehnder M. Factors affecting the
outcome of orthograde root canal therapy in a general dentistry hospital
practice. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2005;99:119–24.
Ørstavik D, Horsted-Bindslev P. A comparison of endodontic treatment results at two dental schools. Int Endod J 1993;26:348–54.
Ørstavik D. Time-course and risk analyses of the development and
healing of chronic apical periodontitis in man. Int Endod J
1996;29:150–5.
JOE — Volume 35, Number 12, December 2009
Review Article
TABLE 1. Normal Pulp: Treatment, Citations, Level of Evidence
Pulpal Diagnosis
Normal Pulp
Treatment
Citations
Level of evidence
1. No Treatment
2. Non-Surgical Root
Canal Therapy, only
in support of other
therapies.
1. No support required
2. a.Torabinejad M, Kutsenko D, MachnickTK, Ismail A,
Newton CW. Levels of evidence for the outcome of
nonsurgical endodontic treatment. J Endod
2005;31:637-46.
2.b. Orstavik D, Quist V, Stoltze K. A multivariate
analysis of the outcome of endodontic treatment.
Eur J OralSci2004;112:224-30.
2.c. Stoll R, Betke K, Stachniss V. The influence of
different factors on the survival of root canal fillings:
a 10-year retrospective study. J Endod 2005;31:78390.
2.d. Marquis VL, DaoT, Farzaheh M, Abitbol S,
Friedman S. Treatment outcome in endodontics: the
Toronto study. Phase III: initial treatment. J Endod
2006;32:299-306.
2.e. Molander A, Warfvinge J, Reit C, Kvist T. Clinical
and radiographic evaluation of one- and two-visit
endodontic treatment of asymptomatic necrotic
teeth with apical periodontitis: a randomized
clinical trial. J Endod 2007;33:1145-8.
2.f. Chugal NM, Clive JM, Spangberg L. Endodontic
treatment outcome: effect of the permanent
restoration. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2007;104:576-82.
2.g. Chen S-C, Chueh L-H, Hsiao CK, Tsai M-Y, Ho S-C,
Chiang C-P. An epidemiologic study of tooth
retention after nonsurgical endodontic treatment in
a large population in Taiwan. J Endod 2007;33:226-9.
2.h. Figini L, Lodi G, Gorni F, Gagliani M. Single versus
multiple visits for endodontic treatment of
permanent teeth. Cochran Database of Systematic
Reviews 2007, Issue 4. Art. No.: CD005296. DOI:
10.1002/14651858.CD005296.pub2.
2.i. de Chevigny C, DaoTT, Rasrani BR, Varquis V,
Farzaheh M, Abithol S, Friedman S. Treatment
outcome in endodontics: the Toronto study - phase
4: initial treatment. J Endod 2008;34:258-63.
2.j. Penesis VA, Fitzgerald PI, Fayad Ml, Wenckus CS,
BeGole EA, Johnson BR. Outcome of one-visit and
two-visit endodontic treatment of necrotic teeth
with apical periodontitis: a randomized controlled
trial with one-year evaluation. J Endod 2008;34:2517.
2.k. Ng YL, Mann V, Rahbaran S, LewseyJ, Gulabivala K.
Outcome of primary root canal treatment:
systematic review of the literature- Part 1. Effects of
study characteristics on probability of success. Int
Endod J 2007;40:921-39.
2.l. NgYL, Mann V, Rahbaran S, LewseyJ, Gulabivala K.
Outcome of primary root canal treatment:
systematic review of the literature- Part 2. Influence
of clinical factors. Int Endod J 2008;41:6-31.
2.m. Orstavik D, Pitt Ford T. Essential Endodontology.
2nd ed. Oxford UK: Blackwell, 2008:316-46.
2.n. Farzaneh M. Abitbol S. Lawrence HP, Friedman S.
Treatment outcome in endodontics-the Toronto
Study. Phase II: initial treatment. J Endod
2004;30:302-9.
1. No support required
2.a. Review of 306 Outcome
Studies–6 LOE1, 26 LOE2,
274 L0E3 or lower.
Ørstavik D, Qvist V, Stoltze K. A multivariate analysis of the outcome
of endodontic treatment. Eur J Oral Sci 2004;112:224–30.
Peters LB, Wesselink PR. Periapical healing of endodontically
treated teeth in one and two visits obturated in the presence or absence
of detectable microorganisms. Int Endod J 2002;35:660–7.
Peters OA, Barbakow F, Peters CI. An analysis of endodontic treatment with three nickel-titanium rotary root canal preparation techniques. Int Endod J 2004;37:849–59.
JOE — Volume 35, Number 12, December 2009
2.b.–LOE3b
2.c.–LOE4
2.d.–LOE4
2.e.–LOE4
2.f.–LOE4
2.g.–LOE4
2.h.–LOE2a
2.i.–LOE4
2.j.–LOE2b
2.k & l.–Review of 63
Outcome Studies
–6 LOE 1, 7 L0E2,
48 L0E3 or lower
2.m–LOE4
2.n.–LOE4
Rahbaran S, Gilthorpe MS, Harrison SD, et al. Comparison of clinical outcome of periapical surgery in endodontic and oral surgery units
of a teaching dental hospital: a retrospective study. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2001;91:700–9.
Sjogren U, Hagglund B, Sundqvist G, et al. Factors affecting the
long-term results of endodontic treatment. J Endod 1990;16:498–504.
Sjogren U, Figdor D, Persson S, et al. Influence of infection at the
time of root filling on the outcome of endodontic treatment of teeth with
Endodontic Treatment Modalities
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Review Article
TABLE 2. Reversible Pulpitis: Treatment, Citations, Level of Evidence
Pulpal Diagnosis
Reversible Pulpitis
Treatment
No Treatment
1. Direct Pulp Capping
2. Indirect Pulp Capping
3. Pulpotomy
4. Non-Surgical Root Canal
Therapy, only in support
of other therapies.
Citations
Level of evidence
No support required
1. a. Matsuo T, Nakanishi T, Shimizu H, Ebisu S. A
clinical study of direct pulp capping applied to
carious-exposed pulps. J Endod 1996;22:551-6.
1.b. Barthel CR, Rosenkranz B, Leuenberg A,
Roulet JF. Pulp capping of carious exposures:
treatment outcome after 5 and 10 years;
a retrospective study. J Endod 2000;26:525-8.
1.c. Farsi N, Alamoudi N, Balto K, Al Mushayt A.
Clinical assessment of mineral trioxide
aggregate (MTA) as direct pulp capping in
young permanent teeth. J Clin Pediatr Dent
2006;31:72-6.
1.d. Al-Hiyasat AS, Barrieshi-Nusair KM, Al-Omari
MA. The radiographic outcomes of direct pulpcapping procedures performed by dental
students. A retrospective study. J Am Dent
Assoc 2006;137:1699-1705.
1.e. Miyashita H, Worthington HV, Qualtrough A,
Plasschaert A. Pulp management for caries in
adults: maintaining pulp vitality. Cochran
Database of Systematic Reviews 2007, Issue 2.
Art. No.:CD0044S4. DOI: 10.1002/
14651S5S.CD0044S4.pub2.
1.f. Orstavik D, Pitt Ford T. Essential
Endodontology. 2nd ed. Oxford UK: Blackwell,
2008:297-315.
1.g. Bogen G, Kim JS, Bakland, LK. Direct pulp
capping with mineral trioxide aggregate: an
observational study. JADA 2008;139:305-315
2. a. Maltz M, Oliveira EF, Fontanella V,
Carminatti G. Deep caries lesions after
incomplete dentine caries removal: 40-month
follow-up study. Caries Res 2007;41:493-6.
2.b. Ricketts DNJ, Kidd EAM, Innes N, Clarkson J.
Complete or ultraconservative removal of
decayed tissue in unfilled teeth. Cochrane
Database of Systematic Reviews 2006, Issue 3.
Art. No.: CD003808. DOI: 10.1002/14651858.CD
003808.pub2.
2.c Orstavik D, Pitt Ford T. Essential
Endodontology. 2nd ed. Oxford UK: Blackwell,
2008:297-315.
3. a. WalyNG. A five-year comparative study of
calcium hydroxide-glutaraldehyde
pulpotomies versus calcium hydroxide
pulpotomies in young permanent molars.
Egypt Dent J 1995;41:993-1000.
3.b. Witherspoon DE, Small JC, Harris GZ. Mineral
trioxide aggregate pulpotomies. A case series
outcomes assessment. J Am Dent Assoc
2006;137:610-8.
3.c. Qudeimat MA, Barrieshi-Nusair KM, Owais
Al. Calcium hydroxide vs mineral trioxide
aggregates for partial pulpotomy of
permanent molars with deep caries. Eur Arch
Paediatr Dent 2007;8:99-104.
3.d. Orstavik D, Pitt Ford T. Essential
Endodontology. 2nd ed. Oxford UK: Blackwell,
2008:297-315.
4.a.Torabinejad M, Kutsenko D, Machnick TK,
Ismail A, Newton CW. Levels of evidence for
the outcome of nonsurgical endodontic
treatment. J Endod 2005;31:637-46.
4.b. Orstavik D, Quist V, Stoltze K. A multivariate
analysis of the outcome of endodontic
treatment. Eur J OralSci2004;112:224-30.
4.c. Stoll R, Betke K, Stachniss V. The influence of
different factors on the survival of root canal
fillings: a 10-year retrospective study. J Endod
2005;31:783-90.
No support required
1.a.–L0E3b
1.b.–L0E4
1.c.–L0E4
1.d.–L0E4
1.e.–LOEla
1.f.–L0E4
1.g.–L0E4
2.a.–LOE3b
2.b.–L0Ela
2.c.–LOE4
3.a–LOE3b
3.b–LOE3b
3.c–LOE3b
3.d.–LOE4
4.a. Review of 306
Outcome Studies–6 L0E1,
26 LOE2,274 L0E3 or lower.
4.b.–LOE3b
4.c.–LOE4
(Continued )
1680
Rosenberg et al.
JOE — Volume 35, Number 12, December 2009
Review Article
TABLE 2. (Continued )
Pulpal Diagnosis
Treatment
Citations
Level of evidence
4.d. Marquis VL, DaoT, Farzaheh M, Abitbol S,
Friedman S. Treatment outcome in
endodontics: the Toronto study. Phase III:
initial treatment. J Endod 2006;32:299-306.
4.e. Molander A, Warfvinge J, Reit C, Kvist T.
Clinical and radiographic evaluation of oneand two-visit endodontic treatment of
asymptomatic necrotic teeth with apical
periodontitis: a randomized clinical trial. J
Endod 2007;33:1145-8.
4.f. Chugal NM, Clive JM, Spangberg L.
Endodontic treatment outcome: effect of the
permanent restoration. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2007;104:57682.
4.g. Chen S-C, Chueh L-H, Hsiao CK, Tsai M-Y, Ho
S-C, Chiang C-P. An epidemiologic study of
tooth retention after nonsurgical endodontic
treatment in a large population in Taiwan. J
Endod 2007;33:226-9.
4.h. Figini L, Lodi G, Gorni F, Gagliani M. Single
versus multiple visits for endodontic treatment
of permanent teeth. Cochran Database of
Systematic Reviews 2007, Issue 4. Art. No.:
CD005296. DOI: 10.1002/
14651858.CD005296.pub2.
4.i. de Chevigny C, DaoTT, Rasrani BR, Varquis V,
Farzaheh M, Abithol S, Friedman S. Treatment
outcome in endodontics: the Toronto study phase 4: initial treatment. J Endod
2008;34:258-63.
4.j. Penesis VA, Fitzgerald PI, Fayacl Ml, Wenckus
CS, BeGole EA, Johnson BR. Outcome of onevisit and two-visit endodontic treatment of
necrotic teeth with apical periodontitis:
a randomized controlled trial with one-year
evaluation. J Endod 2008;34:251-7.
4.k. Ng YL, Mann V, Rahbaran S, LewseyJ,
Gulabivala K. Outcome of primary root canal
treatment: systematic review of the literaturePart 1. Effects of study characteristics on
probability of success. Int Endod J2007;40:92139.
4.l. NgYL, Mann V, Rahbaran S, LewseyJ,
Gulabivala K. Outcome of primary root canal
treatment: systematic review of the literature Part 2. Influence of clinical factors. Int Endod J
200S;41:6-31.
4.m. Orstavik D, Pitt Ford T. Essential
Endodontology. 2nd ed. Oxford UK: Blackwell,
2008:316-46.
4.n. Farzaneh M. Abitbol S. Lawrence HP,
Friedman S. Treatment outcome in
endodontics- the Toronto Study. Phase II: initial
treatment. J Endod 2004;30:302-9.
4.d.–LOE4
apical periodontitis [published erratum appears in Int Endod J 1998
Mar;31:148]. Int Endod J 1997;30:297–306.
Strindberg L. The dependence of the results of pulp therapy on
certain factors. Ana analytic study based on radiographic and clinical
follow-up examination. Acta Odontol Scand 1956;14(Suppl 21):1-175.
Trope M, Delano EO, Ørstavik D. Endodontic treatment of teeth
with apical periodontitis: single vs. multivisit treatment. J Endod
1999;25:345–50.
Weiger R, Rosendahl R, Lost C. Influence of calcium hydroxide intracanal dressings on the prognosis of teeth with endodontically
induced periapical lesions. Int Endod J 2000;33:219–26.
JOE — Volume 35, Number 12, December 2009
4.e.–LOE4
4.f.–L0E4
4.g.–LOE4
4.h.–LOE2a
4 i.–LOE4
4.j.–LOE2b
4.k & l.–Review of
63 Outcome Studies
–6 LOE 1, 7 L0E2,
48 L0E3 or lower
4.m–LOE4
4.n.–LOE4
Zuolo ML, Ferreira MO, Gutmann JL. Prognosis in periradicular
surgery: a clinical prospective study. Int Endod J 2000;33:91–8.
Subquestion #4a: What Are the Pros and Cons
of a Postoperative Diagnosis?
Establishing a preoperative pulpal and periapical diagnosis
requires the clinician to use information gained from three distinct
sources. The first source is the patient’s report of the history and current
interpretation of the chief complaint. The second source is comprised
of the observations obtained from the clinical examination of the patient
Endodontic Treatment Modalities
1681
Review Article
TABLE 3. Irreversible Pulpitis: Treatment, Citations, Level of Evidence
Pulpal Diagnosis
Irreversible
Pulpitis
Treatment
Citations
1. Non-Surgical
Root Canal Therapy
1.a.Torabinejad M, Kutsenko D, MachnickTK, Ismail A,
Newton CW. Levels of evidence for the outcome of
nonsurgical encloclontic treatment. J Enclocl
2005;31:637-46.
1.b. Orstavik D, Quist V, Stoltze K. A multivariate
analysis of the outcome of encloclontic treatment.
Eur J OralSci2004;112:224-30.
1.c. Stoll R, Betke K, Stachniss V. The influence of
different factors on the survival of root canal fillings:
a 10-year retrospective study. J Endod 2005;31:78390.
1.d. Marquis VL, DaoT, Farzaheh M, Abitbol S, Friedman
S. Treatment outcome in endodontics: the Toronto
study. Phase III: initial treatment. J Endod
2006;32:299-306.
1.e. Molander A, Warfvinge J, Reit C, Kvist T. Clinical and
radiographic evaluation of one- and two-visit
endodontic treatment of asymptomatic necrotic
teeth with apical periodontitis: a randomized clinical
trial. J Endod 2007;33:1145-S.
1.f. Chugal NM, Clive JM, Spangberg L. Endodontic
treatment outcome: effect of the permanent
restoration. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2007;104:576-82.
1.g. Chen S-C, Chueh L-H, Hsiao CK, Tsai M-Y, Ho S-C,
Chiang C-P. An epidemiologic study of tooth
retention after nonsurgical endodontic treatment in
a large population in Taiwan. J Endod 2007;33:226-9.
1.h. Figini L, Lodi G, Gorni F, Gagliani M. Single versus
multiple visits for endodontic treatment of
permanent teeth. Cochran Database of Systematic
Reviews 2007, Issue 4. Art. No.: CD005296. DOI:
10.1002/14651858.CD005296.pub2.
1.i. de Chevigny C, DaoTT, Rasrani BR, Varquis V,
Farzaheh M, Abithol S, Friedman S. Treatment
outcome in endodontics: the Toronto study - phase 4:
initial treatment. J Endod 2008;34:258-63.
1.j. Penesis VA, Fitzgerald PI, Fayad Ml, Wenckus CS,
BeGole EA, Johnson BR. Outcome of one-visit and
two-visit endodontic treatment of necrotic teeth with
apical periodontitis: a randomized controlled trial
with one-year evaluation. J Endod 2008;34:251-7.
1.k. Ng YL, Mann V, Rahbaran S, LewseyJ, Gulabivala K.
Outcome of primary root canal treatment: systematic
review of the literature- Part 1. Effects of study
characteristics on probability of success. Int Endod J
2007;40:921-39.
1.l. NgYL, Mann V, Rahbaran S, LewseyJ, Gulabivala K.
Outcome of primary root canal treatment: systematic
review of the literature - Part 2. Influence of clinical
factors. Int Endod J 2008;41:6-31.
1.m. Orstavik D, Pitt Ford T. Essential Endodontology.
2nd ed. Oxford UK: Blackwell, 2008:316-46.
1.n. Farzaneh M. Abitbol S. Lawrence HP, Friedman S.
Treatment outcome in endodontics-the Toronto
Study. Phase II: initial treatment. J Endod
2004;30:302-9.
and the results of commonly used clinical tests, including thermal, electric, percussion, palpation, and mobility. The third source is the interpretation of images produced by a variety of imaging techniques,
including conventional and digital periapical or panoramic radiographs, computed tomography scans, cone beam-computed tomography, and micro-CT scans.
Unfortunately, the first two sources of information along with
imaging using conventional or digital periapical or panoramic radiography are frequently subject to error. For instance, the accuracy of
1682
Rosenberg et al.
Level of evidence
1.a. Review of 306
Outcome Studies–6 L0E1,
26 LOE2,274 L0E3 or lower.
1.b.–L0E3b
1.c.–LOE4
1.d.–L0E4
1.e.–LOE4
1.f.–L0E4
1.g.–L0E4
1.h.–L0E2a
1.i.–L0E4
1.j.–L0E2b
1.k & l.–Review of
63 Outcome Studies
–6 LOE1, 7 L0E2,
48 L0E3 or lower
1.m.–LOE4
1.n.–LOE4
a variety of pulp vitality tests commonly used by the clinician consistently
fall short of the gold standard of 100% (1–4). Petersson et al (4) found
that the positive and negative predictive values for the cold test were 0.89
and 0.90, for the heat test 0.48 and 0.83, and for the electric pulp test
0.88 and 0.84, respectively (4). Low et al (5) reported that 34% more
endodontic lesions were seen radiographically when limited conebeam tomography scans were used in maxillary posterior teeth referred
for possible endodontic surgery than when conventional periapical
radiography was used (5). It is well documented that patient reports
JOE — Volume 35, Number 12, December 2009
Review Article
TABLE 4. Pulp Necrosis: Treatment, Citations, Level of Evidence
Pulpal Diagnosis
Pulp Necrosis
Treatment
Citations
1. Non-Surgical
Root Canal Therapy
1.a.Torabinejad M, Kutsenko D, MachnickTK, Ismail
A, Newton CW. Levels of evidence for the outcome
of nonsurgical encloclontic treatment. J Enclocl
2005;31:637-46.
1.b. Orstavik D, Quist V, Stoltze K. A multivariate
analysis of the outcome of encloclontic treatment.
Eur J OralSci2004;112:224-30.
1.c. Stoll R, Betke K, Stachniss V. The influence of
different factors on the survival of root canal
fillings: a 10-year retrospective study. J Endod
2005;31:783-90.
1.d. Marquis VL, DaoT, Farzaheh M, Abitbol S,
Friedman S. Treatment outcome in endodontics:
the Toronto study. Phase III: initial treatment. J
Endod 2006;32:299-306.
1.e. Molander A, Warfvinge J, Reit C, Kvist T. Clinical
and radiographic evaluation of one-and two-visit
endodontic treatment of asymptomatic necrotic
teeth with apical periodontitis: a randomized
clinical trial. J Endod 2007;33:1145-8.
1.f. Chugal NM, Clive JM, Spangberg L. Endodontic
treatment outcome: effect of the permanent
restoration. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2007;104:576- 82.
1.g. Chen S-C,Chueh L-H, Hsiao CK.Tsai M-Y, Ho S-C,
Chiang C-P. An epidemiologic study of tooth
retention after nonsurgical endodontic treatment
in a large population in Taiwan. J Endod
2007;33:226-9.
1.h. Figini L, Lodi G, Gorni F, Gagliani M. Single versus
multiple visits for endodontic treatment of
permanent teeth. Cochran Database of Systematic
Reviews 2007, Issue 4. Art. No.: CD005296.DOI:
10.1002/14651858.CD005296.pub2.
1.i. de Chevigny C, DaoTT, Rasrani BR, Varquis V,
Farzaheh M, Abithol S, Friedman S. Treatment
outcome in endodontics: the Toronto study- phase
4: initial treatment. J Endod 2008;34:25S-63.
1.j. Penesis VA, Fitzgerald PI, Fayad Ml, Wenckus CS,
BeGole EA, Johnson BR. Outcome of one-visit and
two-visit endodontic treatment of necrotic teeth
with apical periodontitis: a randomized controlled
trial with one-year evaluation. J Endod
2008;34:251-7.
1.k. Ng YL, Mann V, Rahbaran S, LewseyJ, Gulabivala
K. Outcome of primary root canal treatment:
systematic review of the literature-Part 1. Effects of
study characteristics on probability of success. Int
Endod J 2007;40:921-39.
1.l. NgYL, Mann V, Rahbaran S, LewseyJ, Gulabivala K.
Outcome of primary root canal treatment:
systematic review of the literature-Part 2. Influence
of clinical factors. Int Endod J 2008;41:6-31.
1.m. Orstavik D, Pitt Ford T. Essential Endodontology.
2nd ed. Oxford UK: Blackwell, 2008:347-80.
1.n. Farzaneh M. Abitbol S. Lawrence HP, Friedman S.
Treatment outcome in endodontics-the Toronto
Study. Phase II: initial treatment. J Endod
2004;30:302-9.
2.a. Johnson WT, Goodrich JL, James GA.
Replantation of avulsed teeth with immature root
development. Oral Surg Oral Med Oral Pathol
1985;60:420-7.
2.b. Kling M, Cvek M, Majare 1. Rate and
predictability of pulp revascularization in
lOtherapeutically reimplanted permanent incisors.
Endod Dent Traumatol 1986;2:83-9.
2.c. Iwaya SI, Ikawa M, Kubota M. Revascularization
of an immature permanent tooth with apical
periodontitis and sin us tract. Dent Traumatol
2001;17:185-7.
2. Regenerative/
Revascularization
Level of evidence
1.a. Review of 306
Outcome Studies–6 LOE1,
26 LOE2, 274 L0E3 or lower.
1.b.–L0E3b
1.c.–LOE4
1.d.–L0E4
1.e.–LOE4
1.f.–L0E4
1.g.–L0E4
1.h.–L0E2a
1.i–L0E4
1.j.–L0E2b
1.k & l.–Review of
63 Outcome Studies
–6 LOE1, 7 L0E2,
48 L0E3 or lower
1.m.–LOE4
1.n.–LOE4
2.a–f–AII LOE4
(Continued )
JOE — Volume 35, Number 12, December 2009
Endodontic Treatment Modalities
1683
Review Article
TABLE 4. (Continued )
Pulpal Diagnosis
Treatment
Citations
Level of evidence
2.d. Banchs F, Trope M. Revascularization of immature
permanent teeth with apical periodontitis: new
treatment protocol? J Endod 2004;30:196-200.
2.e. Chueh L-H, Huang GT-J. Immature teeth with
periradicular periodontitis or abscess undergoing
apexogenesis: a paradigm shift. J Endod
2006;32:1205-13.
2.f. Cotti 1, Mereu M, Lusso D. Regenerative
treatment of an immature, traumatized tooth with
apical periodontitis: report of a case. J Endod
2008;34:611-6.
2.g. Murray PE, BSc, Garcia-Godoy F, Hargreaves KM.
Regenerative Endodontics: A Review of Current
Status and a Call for Action. J Endod 2007;33:377-390
are very subjective and influenced by a multitude of factors ranging from
cultural and ethnic background to the category or rank of anxietyproducing stimuli (6).
Because of the inherent error in the information-gathering
methods used by clinicians, the preoperative endodontic diagnosis is,
in reality, a tentative diagnosis. However, regardless of its tentative
nature, initial treatment planning decisions are and will be dependent
on this phase of information gathering and interpretation. In some
cases, however, it is only after direct macroscopic or microscopic
examination of pulpal and periapical tissues or by observing the course
of endodontic disease or other disease entity during or after treatment
can a definitive diagnosis be made. This is especially true of periapical
disease. If the overall objective of establishing a diagnosis is to approach
or attain 100% accuracy in the identification of normal or pathologic
conditions in order to synthesize an effective treatment plan, then the
postoperative diagnosis is essential.
Reliance on the preoperative diagnosis alone can lead to misdiagnosis. In some instances, a misdiagnosis of pulpal disease is inconsequential because the treatment plan or its implementation would
have been the same or similar for the real or the erroneously diagnosed
disease entity or normal condition. In other instances, the misdiagnosis
may result in unnecessary endodontic treatment. For periapical disease,
the stakes can be much higher. A misdiagnosis of periapical disease may
have far-reaching consequences that may place the patient in jeopardy
because of spreading or fulminating infections, neoplastic disease, or
other serious conditions (7–9). Because of the serious or even mortal
consequences of misdiagnosis, it is compelling to establish an accurate
(definitive) postoperative diagnosis.
The consequences for the patient of errors in preoperative diagnosis, which lead to mistakes in treatment selection or omissions, range
from minimal to serious to life threatening. In today’s litigious society,
these errors in diagnosis can and often do result in malpractice suits,
large settlements, ruined professional reputations, and irrevocable
negative entries in the National Practitioner Data Bank. The reality of
the legal ramifications of erroneous preoperative diagnosis clearly
speaks for adopting practice behaviors that provide greater accuracy
of diagnosis in a timely manner. The more objective methods used to
establish a postoperative diagnosis typify those behaviors.
Subquestion #4b: If Different from Preoperative
Diagnosis, Should the Postoperative Diagnosis
Be the More Definitive Diagnosis in Every Case?
If we accept the premise that a preoperative diagnosis is a tentative
diagnosis, albeit an essential one to develop a treatment plan, then it
1684
Rosenberg et al.
2.g. Review,
summarizing current
knowledge
follows that we can confirm an accurate tentative (preoperative) diagnosis postoperatively or discover the inaccuracy of the initial diagnosis.
This is achieved during or after the treatment intervention by direct
observation of pulpal tissues, microbiological sampling, histopathologic examination of periapical tissues, or recalls of patients to assess
the course of healing or nonhealing of diseased tissues. Executing the
sequence of actions from preoperative diagnosis to treatment planning
to definitive diagnosis postoperatively then becomes the gold standard
for clinical practice. Philosophically, because the gold standard represents the very best that can be attained by known means and the best that
the clinician can offer the patient, it should be required in every case.
If the postoperative diagnosis is the most accurate because of more
objective and direct methods of data collection, then this improved
accuracy provides the impetus to change the initial diagnosis if it is
wrong. It also follows that if a postoperative diagnosis is different
from the preoperative diagnosis, the postoperative diagnosis will be
more accurate than the preoperative diagnosis.
From a purist’s point of view, a more accurate diagnosis is a more
definitive diagnosis. A more definitive diagnosis increases the probability of selecting a better treatment plan for the patient. This, in turn,
provides the opportunity for the clinician to provide the patient with
a more accurate prediction of treatment outcome. Finally, better treatment leads to better outcomes.
As has been eluded to previously in this article, the implications of
failing to make a definitive diagnosis postoperatively when there is an
erroneous preoperative diagnosis, especially for periapical disease,
can be ominous. It is the clinician’s responsibility and obligation to
avoid failing to recognize the existence, nature, and importance of
disease processes that can lead to patient morbidity or mortality.
Thus, a definitive diagnosis, whether it is confirmed after the preoperative diagnosis is made or obtained de novo postoperatively, is mandatory. The definitive diagnosis is central to the timely modification of
a treatment plan to best treat the patient when a preoperative (tentative)
diagnosis is misleading or inaccurate.
Based on the previously described argument, when the postoperative diagnosis differs from the preoperative diagnosis, the postoperative diagnosis is the more definitive and will be in every case. To believe
otherwise tempts the clinician to group clinical situations in which
differences in pre- and postoperative diagnoses have no material effect
on outcomes together with those in which those differences carry negative consequences for the patient. This creates the situation in which the
clinician operates under two different standards of care and exercises
two different sets of practice behaviors. This is contrary to and incompatible with the lofty goal of providing all patients with the same opportunity for equal access to and the benefit of the gold standard of care.
JOE — Volume 35, Number 12, December 2009
Review Article
TABLE 5. Previously Treated: Treatment, Citations, Level of Evidence
Pulpal Diagnosis
Previously Treated
Treatment
1. Non-Surgical
Retreatment
2. Periradicular Surgery
3. Intentional Replantation
Citations
Level of evidence
1.a. PaikS, Sechreist C.Torabinejad M. Levels of
evidence for the outcome of encloclontic
retreatment. J Endod 2004;30:745-50.
1.b. Gorni FG, Gagliani MM. The outcome of
endodontic retreatment: A 2-yr follow-up. J
Endod 2004;30:l-4.
1.c. Yoldas 0, Topuz A, Isci AS, Oztunc H.
Postoperative pain after endodontic
retreatment: Single-versus two-visit
treatment. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2004;98:483-7.
1.d. Orstavik D, Pitt Ford T. Essential
Endodontology. 2nd ed. Oxford UK: Blackwell,
2008:347-80.
1.e. Kvist T, Reit C. Results of endodontic
retreatment: a randomized clinical study
comparing surgical and nonsurgical
procedures. J Endod 1999;25:814-17
2.a. Mead C, Javida-Nejad S, Mego ME, Nash B,
Torabinejad M. Levels of evidence for the
outcome of endodontic surgery. J Endod
2005;31:19-24.
2.b. Del Fabbro M, Taschieri S, Testori T, Francetti
L, Weinstein RL. Surgical versus non-surgical
endodontic retreatment for periradicular
lesions. Cochrane Database of Systemic
Reviews 2007, Issue 3. Art. No.: CD005511. DOI:
10.1002/14651858.CD005511.publ.
2.c. Gagliani MM, Gorni FG, Strohmenger L.
Periapical resurgery versus periapical surgery:
a 5-year longitudinal comparison. Int Endod J
2005;38:320-7.
2.d. Friedman S. The prognosis and expected
outcome of apical surgery. Endod Topics 2005;
11:219-62.
2.e. Penarrocha M, Marti E, Garcia B, Gay C.
Relationship of periapical lesion radiologic
size, apical resection, and retrograde filling
with the prognosis of periapical surgery. J Oral
Max Surg, 2007;65:1526-9.
2.f. von Arx T.Jensen SS, Hanni S. Clinical and
radiographic assessment of various predictors
for healing outcome 1 year after periapical
surgery. J Endod 2007;33:123-8.
2.g. Orstavik D, Pitt Ford T. Essential
Endodontology. 2nd ed. Oxford UK: Blackwell,
2008:381-407.
2.h. Kvist T, Reit C. Results of endodontic
retreatment: a randomized clinical study
comparing surgical and nonsurgical
procedures. J Endod 1999;25:814-17
2.i. Wang N, Knight K, Dao T, Friedman S.
Treatment outcome in endodontics - the
toronto study: phases 1 and II: apical surgery. J
Endod 2004;30:751-761.
2.j. Lindeboom JA, Frenken JW, Kroon FH, van
den Akker HP. A comparative prospective
radomized clinical study of MTA and IRM as
root-end filling materials in single-rooted
teeth in endodontic surgery. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod
2005;100:495-500.
3.a. Orstavik D, Pitt Ford T. Essential
Endodontology. 2nd ed. Oxford UK: Blackwell,
2008:452-4.
3.b. Koenig KH, Nguyen NT, Barkhordar RA.
Intentional replantation: a report of 192 cases.
Gen Dent 1988;36:327-31.
1.a. Review of 37 Outcome
Studies–0 LOE1, 1 LOE2,
0 LOE3&4, 18 L0E5.
1.b.–L0E3b
1.c.–L0E3b
1.d.–L0E4
1.e.–LOE2b
2.a. Review of 79 Outcome
Studies -0 LOE1,7 LOE2,
12 LOE3, 60 LOE4.
2.b.–L0Ela
2.c.–LOE2b
2.d.–LOE2b
2.e.–LOE3b
2.f.–LOE3b
2.g.–LOE4
2.h.–LOE2b
2.i.–LOE4
2.j.–LOE2a
3.a.–LOE4
3.b.–LOE4
(Continued )
JOE — Volume 35, Number 12, December 2009
Endodontic Treatment Modalities
1685
Review Article
TABLE 5. (Continued )
Pulpal Diagnosis
Treatment
Citations
Level of evidence
3.c. Keller U. A new method of tooth replantation
and auto-transplantation: aluminum oxide
ceramic for extraoral retrograde filling. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod
1990;70:341-4.
3.d. Bender IB, Rossman LE. Intentional
replantation of endodontically treated teeth.
Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 1993;76:623-30.
Subquestion #4 References
1. Hyman JJ, Cohen ME. The predictive value of endodontic diagnostic test. Oral Surg Oral Med Oral Pathol 1984;58:343–6.
2. Fuss Z, Trowbridge H, Bender IB, et al. Assessment of reliability
of electrical and thermal pulp testing agents. J Endod 1986;12:301–5.
3. Peters DD, Baumgartner JC, Lorton L. Adult pulpal diagnosis. I.
Evaluation of the positive and negative responses to cold and electrical
pulp test. J Endod 1994;20:506–11.
4. Petersson K, Soderstrom C, Kiani-Anaraki M, et al. Evaluation of
the ability of thermal and electrical tests to register pulp vitality. Endod
Dent Traumatol 1999;15:127–31.
5. Low KM, Dula K, Bu¨rgin W, et al. Comparison of periapical radiography and limited cone-beam tomography in posterior maxillary
teeth referred for apical surgery. J Endod 2008;34:557–62.
6. Eitner S, Wichmann M, Paulsen A, Holst S. Dental anxiety—an
epidemiological study on its clinical correlation and effects on oral
health. J Oral Rehabil 2006;33:588–593.
7. Garlock JA, Pringle GA, Hicks ML. The odontogenic keratocyst. A
potential endodontic misdiagnosis. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1998;85:452–6.
8. Dahlkemper P, Wolcott JF, Pringle GA, et al. Periapical central
giant cell granuloma: a potential endodontic misdiagnosis. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2000;90:739–45.
9. Kuc I, Peters E. Comparison of clinical and histologic diagnoses
in periapical lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2000;89:333–7.
Subquestion #5: What Are the Indications,
Contraindications, and Prognoses for These
Treatments?
In this review of the literature, the current endodontic diagnostic
terminology derived by the American Board of Endodontics is used.
Possible treatments relative to those diagnostic categories are pulp
capping, pulpotomy, pulpectomy (nonsurgical or orthograde root
canal therapy), apicoectomy, and replantation; these appear as MeSH
terms under ‘‘endodontics.’’ These terms were searched through
PubMed with the additional MeSH terms ‘‘prognosis’’ or ‘‘contraindications.’’ Limits applied to these searches included ‘‘English’’ along with
either ‘‘randomized controlled trial,’’ ‘‘meta-analysis,’’ or ‘‘review.’’
General searches using the same search terms, but without limits,
were also performed. The intention was to find relevant literature on
prognosis of these treatments in adult permanent teeth. Controlled trials
as well as many systematic reviews have been a focused topic of investigation.
Pulp Capping/Pulpotomy
Most investigative work on the outcomes of pulp-capping procedures has been performed on younger patients and on primary teeth.
Investigations of these procedures on permanent teeth in adults are
1686
Rosenberg et al.
3.c.–LOE4
3.d.–LOE4
exceedingly limited. There is a consistent criterion in these studies
that only teeth with deep caries, possibly even carious pulp exposure,
but without spontaneous symptoms be included in the experimental
groups. Teeth with spontaneous symptoms are assumed to be
committed to pulpectomy and complete root canal therapy. This
concept itself, although widely accepted and broadly applied, is drawn
by inference from histopathologic studies of the dental pulp. No study
could be located that directly tested this concept, and it may be warranted to investigate this very fundamental clinical paradigm.
Successful outcome with indirect pulp capping of adult permanent
teeth is reported to be on the order of 80% to 90% (1); direct pulp
capping is reported to be 50% to 80% (2) or as high as 100% (3).
At 3 years, 33% of carious exposures were radiographically successful,
whereas mechanical exposure had 92% success (4). An overall clinical
and radiographic success of 82% was observed for calcium hydroxide
direct pulp caps up to 40 years of age (5) with decreasing success
beyond that age.
Whitworth et al (6) found that the odds ratio of pulp breakdown in
teeth with pulp exposure versus those without was 28.4. The deterioration over time of the prognosis of pulp-capping carious exposures in
adult permanent teeth seems to indicate this procedure is contraindicated as a long-term treatment. Observations made by Matsuo et al
(5) refute this conclusion. In assessing the outcomes of direct pulp
capping (carious exposure) of adult teeth, they found an impressive
success rate of 88.6% when there was slight bleeding versus 55.6%
with conspicuous bleeding. There is a significant drop off in the number
of participants because the study was performed for 36 months so absolute success is speculative, but, of those who returned for follow-up,
success rates remained at 80% to 92%.
Nyborg (7) observed a difference between clinical outcome, based
on signs and symptoms, and histopathologic healing. Fifty-six percent
(41/73) of adult teeth with carious pulp exposure but no prior symptoms were clinically ‘‘successful’’ after pulp capping. On histopathologic
examination of 19 of those cases, only 8 (44%) were considered histopathologically ‘‘successful.’’ Nyborg also makes the observation that
histopathologic and clinical success is more likely in permanent teeth
in children (74% clinical and 68% histopathologic) than in adults.
A case series (LOE 4) reported by Bogen et al (8) included 18 adult
patients aged 16 to 47 years and with 1 to 7 years follow-up. All pulpcapping procedures followed a meticulous treatment protocol, and
MTA was used as the capping material. Thirteen of the 18 teeth (72%)
had radiographically detectable dentin bridges and showed normal clinical pulp responses at final follow-up. The information from Hodosh,
Shovelton, and Whitworth is extracted from a Cochrane Review focusing
on pulp management in adult teeth (9) with an LOE of 2.
Sixty-five percent of teeth in a case series of mostly adult patients
receiving pulpotomy procedures instead of extraction were present and
functioning at last recall (up to 88 months) (10). Up to 30 days, 98% of
pulpotomized teeth may remain symptom free whether a liquid sedative
dressing is used or not (11). For up to 6 months, a hard-setting eugenol
JOE — Volume 35, Number 12, December 2009
Review Article
TABLE 6. Previously Initiated therapy: Treatment, Citations, Level of Evidence
Pulpal Diagnosis
Treatment
Citations
Level of evidence
Previously Initiated
Therapy
1. Non-Surgical
Root Canal Therapy
1.a.Torabinejad M, Kutsenko D, MachnickTK,
Ismail A, Newton CW. Levels of evidence for the
outcome of nonsurgical encloclontic
treatment. J Enclocl 2005;31:637-46.
1.b. Orstavik D, Quist V, Stoltze K. A multivariate
analysis of the outcome of encloclontic
treatment. Eur J OralSci2004;112:224-30.
1.c. Stoll R, Betke K, Stachniss V. The influence of
different factors on the survival of root canal
fillings: a 10-year retrospective study. J Endod
2005;31:783-90.
1.d. Marquis VL, DaoT, Farzaheh M, Abitbol S,
Friedman S. Treatment outcome in
endodontics: the Toronto study. Phase III: initial
treatment. J Endod 2006;32:299-306.
1.e. Molander A, Warfvinge J, Reit C, Kvist T.
Clinical and radiographic evaluation of oneand two-visit endodontic treatment of
asymptomatic necrotic teeth with apical
periodontitis: a randomized clinical trial. J
Endod 2007;33:1145-S.
1.f. Chugal NM, Clive JM, Spangberg L.
Endodontic treatment outcome: effect of the
permanent restoration. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2007;104:57682.
1.g. Chen S-C, Chueh L-H, Hsiao CK, Tsai M-Y, Ho SC, Chiang C-P. An epidemiologic study of tooth
retention after nonsurgical endodontic
treatment in a large population in Taiwan. J
Endod 2007;33:226-9.
1.h. Figini L, Lodi G, Gorni F, Gagliani M. Single
versus multiple visits for endodontic treatment
of permanent teeth. Cochran Database of
Systematic Reviews 2007, Issue 4. Art. No.:
CD005296. DOI: 10.1002/
14651858.CD005296.pub2.
1.i. de Chevigny C, DaoTT, Rasrani BR, Varquis V,
Farzaheh M, Abithol S, Friedman S. Treatment
outcome in endodontics: the Toronto studyphase 4: initial treatment. J Endod 200S;34:25S63.
1.j. Penesis VA, Fitzgerald PI, Fayad Ml, Wenckus
CS, BeGole EA, Johnson BR. Outcome of onevisit and two-visit endodontic treatment of
necrotic teeth with apical periodontitis:
a randomized controlled trial with one-year
evaluation. J Endod 2008;34:251-7.
1.k. Ng YL, Mann V, Rahbaran S, LewseyJ, Gulabivala
K. Outcome of primary root canal treatment:
systematic review of the literature-Part 1. Effects
of study characteristics on probability of success.
Int Endod J 2007;40:921-39.
1.l. NgYL, Mann V, Rahbaran S, LewseyJ,
Gulabivala K. Outcome of primary root canal
treatment: systematic review of the literaturePart 2. Influence of clinical factors. Int Endod J
200S;41:6-31.
1.m. Orstavik D, Pitt Ford T. Essential
Endodontology. 2nd ed. Oxford UK: Blackwell,
2008:347-80.
1.n. Farzaneh M. Abitbol S. Lawrence HP,
Friedman S. Treatment outcome in
endodontics-the Toronto Study. Phase II: initial
treatment. J Endod 2004;30:302-9.
1.a. Review of 306 Outcome
Studies- 6 LOE1, 26 LOE2,
274 L0E3 or lower.
dressing allowed symptom-free retention of 90% of teeth in adults;
however, 51% of those teeth had radiographic changes in that time
period (12). Pulpotomy with or without a sedative dressing may be
an effective temporary palliative treatment for adult permanent teeth.
JOE — Volume 35, Number 12, December 2009
1.b.–L0E3
1.c.–LOE4
1.d.–L0E4
1.e.–LOE4
1.f.–L0E4
1.g.–L0E4
1.h.–L0E2
1.i–L0E4
1.j.–L0E2
1.k & l.–Review of 63 Outcome
Studies–6 LOE1, 7 L0E2,
48 L0E3 or lower
1.m.–LOE4
1.n.–LOE4
As with pulp capping of carious exposures, the prognosis of longterm pulpotomy treatment in adult permanent teeth has been assumed
to be contraindicated but has not been thoroughly investigated with
current materials.
Endodontic Treatment Modalities
1687
Review Article
TABLE 7. Normal: Treatment, Citations, Level of Evidence
Periapical Diagnosis
Treatment
Citations
Normal
Dependent only on
pulpal status
Not applicable
Symptomatic apical
periodontitis
Non-Surgical Root
Canal Therapy
Studies #1-8
Surgical Root
Canal Therapy
Studies #9-16
Non-Surgical Root
Canal Therapy
Studies #1-8
Surgical Root
Canal Therapy
Studies #9-16
Non-Surgical Root
Canal Therapy
Studies #1-8
Surgical Root
Canal Therapy
Studies #9-16
Incision and Drainage
Study #17
Non-Surgical Root
Canal Therapy
Studies #1-8
Surgical Root
Canal Therapy
Studies #9-16
Asymptomatic apical
periodontitis
Acute apical abscess
Chronic apical
abscess
Level of Evidence
l. Torabinejad M, Kutsenko D,
MachnickTK, Ismail A, Newton CW.
Levels of evidenceforthe outcome of
nonsurgicalendodontic treatment.]
Endod 2005;31:637-46.
2. Marquis VL, DaoT, Farzaheh M, Abitbol
S, Friedman S. Treatment outcome in
endodontics: the Toronto study. Phase
III: initial treatment. J Endod
2006:32:299-306.
3. Figini L, Lodi G, Gorni F, Gagliani M.
Single versus multiple visits for
endodontic treatment of permanent
teeth. Cochran Database of Systematic
Reviews 2007, Issue 4. Art. No.:
CD005296. DOI: 10.1002/
14651858.CD005296.pub2.
4. de Chevigny C, DaoTT, Basrani BR,
Varquis V, Farzaheh M, Abithol S,
Friedman S. Treatment outcome in
endodontics: the Toronto study- phase
4: initial treatment. J Endod
2008;34:258-63.
5. Penesis VA, Fitzgerald PI, Fayad Ml,
WenckusCS, BeGole EA, Johnson BR.
Outcome of one-visit and two-visit
endodontic treatment of necrotic teeth
with apical periodontitis: a randomized
controlled trial with one-year
evaluation.] Endod 2008:34:251-7.
6. Ng YL, Mann V, Rahbaran S, Lewsey J,
Gulabivala K. Outcome of primary root
canal treatment: systematic review of
the literature - Part 1. Effects of study
characteristics on probability of success.
Int Endod J 2007;40:921-39.
7. Ng YL, Mann V, Rahbaran S, Lewsey J,
Gulabivala K. Outcome of primary root
canal treatment: systematic review of
the literature - Part 2. Influence of
clinical factors. Int Endod J 2008;41:6-31.
8. Farzaneh M. Abitbol S. Lawrence HP,
Friedman S. Treatment outcome in
endodontics-the Toronto Study. Phase II:
initial treatment. J Endod 2004:30:3029.
9. Mead C, Javida-Nejad S, Mego ME, Nash
B, Torabinejad M. Levels of evidence
forthe outcome of endodontic surgery. J
Endod 2005:31:19-24.
10. Del Fabbro M.TaschieriS,Testori T,
Francetti L, Weinstein RL Surgical versus
non-surgical endodontic retreatment
for periradicular lesions. Cochrane
Database of Systemic Reviews 2007,
Issue 3. Art. No.: CD005511.
DOI:10.1002/14651858.CD005511.publ.
11. Gagliani MM, Gorni FG, Strohmenger L
Periapical resurgery versus periapical
surgery: a 5-year longitudinal
comparison. Int Endod J 2005;38:320-7.
12. Friedman S. The prognosis and
expected outcome of apical surgery.
Endod Topics 2005;11:219-62.
13. KvistT, Reit C. Results of endodontic
retreatment: a randomized clinical
study comparing surgical and
nonsurgical procedures. J Endod
1999;25:814-17
L0E2a
L0E4
L0E2a
L0E4
L0E2b
L0E2a
LOE2a
LOE4
LOE2a
LOE1a
LOE2b
LOE2b
LOE2b
(Continued )
1688
Rosenberg et al.
JOE — Volume 35, Number 12, December 2009
Review Article
TABLE 7. (Continued )
Periapical Diagnosis
Treatment
Citations
Level of Evidence
14. Wang N, Knight K, DaoT, Friedman S.
Treatment outcome in endodontics the
to ronto study: phases land II: apical
surgery. J Endod 2004;30:751-761.
15. Lindeboom JA, Frenken JW, Kroon FH,
van den Akker HP. Acomparative
prospective radomized clinical study of
MTAand IRM as root-end filling
materials in single-rooted teeth in
endodontic surgery. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod
2005;100:495-500.
16. von Arx T, Jensen SS, HanniS. Clinical
and radiographic assessment of various
predictors for healing outcome 1 year
after periapical surgery. J Endod
2007:33:123-8.
17. Matthews DC, Sutherland S, Basrani B.
Emergency management of acute apical
abscesses in the permanent dentition:
a systematic review of the literature.
Journal (Canadian Dental Association)
2003;69(10):660
Pulpectomy/Surgery/Intentional Replantation
Two recent publications arguably represent the most thorough,
insightful, and complete evaluations of endodontic treatment outcomes.
In chapter 14 of the second edition of Essential Endodontology (13),
Friedman reviewed 479 references out of which he identified 22
selected studies concerning initial nonsurgical root canal treatment:
six selected studies pertaining to nonsurgical retreatment, seven studies
for surgical treatment, and 13 for intentional replantation (Friedman’s
complete bibliography is not replicated in this article; however the
selected studies are included in the references with Subquestion #5).
Within the set of 22 initial treatment studies were 4 assessed by Torabinejad et al (14) to be at LOE 1 and 7 at LOE 2. Of the retreatment studies,
Paik et al (15) assessed two to be at LOE 2 and three at LOE 3. The
surgery series included two LOE 2, one LOE 3, and one LOE 4 study according to Mead et al (16). No studies on intentional replantation meet
the criteria of LOE 1 or 2.
In ranking levels of evidence, the Oxford Centre for EvidenceBased Medicine indicates that well-designed cohort studies and particularly good systematic reviews of such studies are of equal or perhaps
even greater value than randomized, controlled studies when evaluating
prognosis (17). This distinction seems to have been applied by Friedman in his selection of articles to be included in his evaluation of
endodontic outcome studies, which includes many cohort studies.
Friedman also makes the observation that the rate of healing is not
consistent from case to case and that a certain period of time, on the
order of years, is necessary for the ultimate outcome of a particular
case to be manifest. Taking into consideration these two thoughts, a third
concept is applied; positive treatment outcome includes both healed
and healing cases, recognizing the dynamic nature of healing after
endodontic therapy. These categories are combined into a ‘‘functional’’
category by Friedman. Not all studies have been presented in these
terms, but where available, Friedman has identified the ‘‘healed,’’ ‘‘healing,’’ and ‘‘functional’’ values. Even within Friedman’s select groups,
there are few studies that fulfill all criteria of a top-quality study with
appropriate duration of follow-up and thorough description of cohort,
treatment, method of healing assessment, and analysis of data.
JOE — Volume 35, Number 12, December 2009
LOE4
LOE2a
LOE2a
LOE2a
A brief summary of Friedman’s material follows:
Initial root canal treatment
Healed
Preop without AP
88%–97%
Preop with AP
74%–91%
Functional
90%–97%
(‘‘Functional’’ includes the sum of AP and no AP). A study with
91% (18) evaluated only teeth without initial AP; three studies with
97% evaluated either cases with AP only (19) or cases with and without
AP [20, 21].)
Nonsurgical retreatment
Healed
Preop withoutAP 93%–97%
Preop with AP
58%–84%
Functional
93%
(‘‘Functional’’ includes the sum of AP and no AP). Data from only
one study could be interpreted with a value for ‘‘functional’’ (22).
Surgical treatment
Healed
37%–91%
Functional
80%–96%
Thirty-seven percent healed and 80% functional are the same
study (23).
Intentional replantation
Success
34%–93%
Survival
71%–100%
A study with 34% success had 80% survival at 1 to 13 years (24).
The second publication is a two-part systematic review written by
Ng et al and published in 2007 and 2008 (25, 26) (LOE 2). They limited
their review to outcomes of initial root canal treatment; 54 studies met
their inclusion criteria. The authors considered two sets of parameters:
those that defined the structure of the study (when and where it was conducted, duration of recall, the strictness of outcome assessment, and
experience of operators) and those that defined the patient and clinical
factors (age and sex, general health, tooth, pulp and periradicular
status, procedures, materials used, quality of treatment, and number
of visits). Interestingly, they found no significant difference in outcome
Endodontic Treatment Modalities
1689
Review Article
rates based on the decade of the study or the geographic region in which
the treatment was rendered. In other words, by this assessment, modern
techniques appear to have not rendered improved outcomes. As with
many other outcomes studies, a lack of homogeneity regarding recall
rates and duration of follow-up must be kept in mind when interpreting
summarized data. A major contribution of these articles is the emphasis
on distinguishing between ‘‘strict’’ and ‘‘loose’’ outcome criteria.
Echoing the actuality stated by Friedman (13) that healing after
endodontic therapy is a dynamic, ongoing process for months to years;
the amount of time that has passed since treatment will have direct
bearing on the radiographic appearance. After a shorter time, ‘‘looser’’
healing criteria are still valid, whereas ‘‘strict’’ healing criteria will be
valid only after sufficient passage of time. The authors state, ‘‘From
a research perspective and based on this review, the cases should be
reviewed for a minimum of 1 year and preferably for at least 3 years,
after completion of treatment’’ and perhaps even a stronger standard
might be applied aiming for the 4- to 5-year recall encouraged by the
American Association of Endodontists and the European Society of
Endodontology.
A brief summary of Ng et al (25) follows:
Initial root canal treatment
Strict (‘‘healed’’)
Preop without AP
72.7%–91.6%
Preop with AP
61.1%–78.1%
Loose (‘‘functional’’)
Preop without AP
86.9%–93.3%
Preop with AP
76.2%–86.6%
The most recent journal articles reviewed by Friedman (13) and
Ng et al (25) were from 2002. A thorough search was conducted for this
consensus project to include applicable references dated 2002 to
present to ensure a complete representation of the literature. In the
Ng review, there were 17 studies identified ranging from case series
to randomized, controlled trials. One study was a Cochrane Review
and another study a CONSORT trial, both of single- versus multiple-visit
treatment. The outcome percentages identified in these studies were
similar to the ranges in Friedman’s work. Not included in Friedman’s
inclusion list for surgical treatment was a systematic review by Peterson
and Gutmann (27), although it is included in the discussion. The
authors reviewed the literature for outcomes of repeat surgery and
found an average healed rate of 36%, a distinctly low positive outcome
implying that resurgery is not an indicated procedure. It should be
noted, however, that seven of the eight included studies were performed
between 1970 and 1987, and so techniques and materials were very
different from current techniques and materials. Wang et al (28) in
the Toronto Study on endodontic surgery using current surgical principles found 63% of eight resurgery cases healed, so it may be imprudent
to assume that resurgery is an absolutely contraindicated procedure. No
additional studies of intentional replantation were identified.
The second of the two articles by Ng et al (26) is a systematic
review of the literature concerning the outcome of secondary root canal
treatment (ie, retreatment). The aims of the study were to investigate the
effects of study characteristics on the reported success rates of root
canal retreatment and to investigate the effects of clinical factors on
the success of retreatment. Of the 40 articles identified, 17 studies published between 1961 and 2005 were included. The majority of studies
were retrospective (n = 12), and only five were prospective. The pooled
estimated success rate of root canal retreatment was 77%. The presence
of a preoperative periapical lesion, apical extent of root filling, and
quality of coronal restoration proved significant prognostic factors
with concurrence between all three strands of evidence, whereas the
effects of primary treatment history and retreatment protocol have
been poorly investigated.
1690
Rosenberg et al.
It was evident that teeth without periapical lesions had 6.32 times
higher odds of success than teeth with periapical lesions. Teeth with
short root fillings had significantly higher success rates than those
with long fillings. Teeth that had been restored or permanently restored
were associated with significantly higher success rates than their counterpart. The type of restoration (29, 30) was found to have no significant
influence on the outcome of secondary root canal treatment.
It has been argued that had dropouts been included in outcome
studies the ultimate results would be skewed in the unfavorable direction. Probably the most challenging aspect of endodontic outcome
studies is following the cohort for an appropriate length of time
(4 years) and maintaining a meaningful percentage of the original
cohort over that time span; the Oxford Centre requires $80%
follow-up retention for a LOE 1 cohort study. This describes a principle
gap in knowledge in understanding the prognosis of endodontic
therapy—studies with well-defined cohorts, treatments, methods of
healing assessment, and analyses of healing assessment coupled with
appropriate follow-up periods and retention of the original cohort to
fairly assess stabilized healing outcomes. It is suggested that a template
for outcome studies be formulated, perhaps by a consensus group,
which meets appropriate follow-up and design characteristics to further
develop our knowledge of endodontic treatment prognosis. Parameters
to be established include standardized outcome metrics, minimum
recall period, and guidelines for the definition of cohort and treatment
data. Correlation of histopathologic conditions with clinical healing
interpretations is critical to validation of outcome assessment. Revisiting
Brynolf’s intent of 1967 and developing acceptable investigative models
to relate histopathologic and clinical appearances are warranted to validate our outcomes assessments.
Subquestion #5 References
1. Maltz M, Oliveira EF, Fontanella V, et al. Deep caries lesions after
incomplete dentine caries removal: 40-month follow-up. Caries Res
2007;41:493–6.
2. Shovelton DS. The maintenance of pulp vitality. Br Dent J
1972;133:95–101.
3. Hodosh M, Hodosh SH, Hodosh AJ. Capping carious exposed
pulps with potassium nitrate, dimethyl isosorbide, polycarboxylate
cement. Dent Today 2003;22:46–51.
4. Al-Hiyasat AS, Barrieshi-Nusair KM, Al-Omari MA. The radiographic outcomes of direct pulp-capping procedures performed by
dental students: a retrospective study. J Am Dent Assoc
2006;137:1699–705.
5. Matsuo T, Nakanishi T, Shimizu H, et al. A clinical study of direct
pulp capping applied to carious-exposed pulps. J Endod 1996;22:551–
6.
6. Whitworth JM, Myers PM, Smith J, et al. Endodontic complications after plastic restorations in general practice. Int Endod J
2005;38:409–16.
7. Nyborg H. Capping of the pulp. The processes involved and their
outcome. Odontol Tidskr 1958;66:296–364.
8. Bogen G, Kim JS, Bakland, LK. Direct pulp capping with mineral
trioxide aggregate: an observational study. J Am Dent Assoc 2008;
139:305–15.
9. Miyashita H, Worthington HV, Qualtrough A, et al. Pulp management for caries in adult: maintaining pulp vitality. Cochrane Database
Syst Rev 2007;2:CD004484.
10. DeRosa TA. A retrospective evaluation of pulpotomy as an
alternative to extraction. Gen Dent 2006;54:37–40.
11. Hasselgren G, Reit C. Emergency pulpotomy: pain relieving
effect with and without use of sedative dressings. J Endod
1989;15:254–6.
JOE — Volume 35, Number 12, December 2009
Review Article
12. McDougal RA, Delano EO, Caplan D, et al. Success of an alternative for interim management of irreversible pulpitis. J Am Dent Assoc
2004;135:1707–12.
13. Friedman S. Expected outcomes in the prevention and treatment of apical periodontitis. In: Ørstavik D, Pitt Ford TE, editors. Essential Endodontology. 2nd ed. Ames, IA: Blackwell; 2008:408–69.
14. Torabinejad M, Kutsenko D, Machnick T, et al. Levels of
evidence for the outcome of nonsurgical endodontic retreatment. J Endod 2005;31:637–45.
15. Paik S, Sechrist C, Torabinejad M. Levels of evidence for the
outcome of endodontic retreatment. J Endod 2004;30:745–50.
16. Mead C, Javidan-Nejad S, Mego ME, et al. Levels of evidence for
the outcome of endodontic surgery. J Endod 2005;31:19–24.
17. Centre for Evidence-Based Medicine. Available at: www.cebm.
net/index.aspx?o=1025. Accessed March 12, 2008.
18. Eriksen HM, Bjertness E, Ørstavik D . Prevalence and quality of
endodontic treatment in an urban adult population in Norway. Endod
Dental Traumatol 1988;4:114–7.
19. Peters L, Wesselink P. Periapical healing of endodontically
treated teeth in one and two visits obturated in the presence or absence
of detectable microorganisms. Int Endod J 2002;35:660–7.
20. Hoskinson SE, Ng YL, Hoskinson AE, et al. A retrospective
comparison of outcome of root canal treatment using two different
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JOE — Volume 35, Number 12, December 2009
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Subquestion #6: What Gaps in Knowledge
Remain for Identifying the Optimal Treatment
Modalities for the Different Diagnostic
Categories?
Significant gaps in knowledge remain for identifying optimal treatment modalities for the different diagnostic categories. With each new
significant development in endodontic technique, equipment, or materials, a new subset of questions become important. For example, what is
the effect of microscopy, rotary instruments, or MTA on endodontic
outcome? There is a gap in knowledge concerning their effect on the
outcome of treatment with respect to the new variables.
Although there exists a commonly referenced, classic study suggesting that systemic health may not play a role in healing ability (1),
there are recent studies suggesting it is an important factor (2, 3).
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The same is true for age and sex, with studies both supporting (4) and
negating (5, 6) its influence. There are also conflicting studies indicating either better healing in single-rooted teeth (7, 8) or better healing
in multirooted teeth (1, 9).
The effect of a positive culture on the outcome of endodontics
remains an area of debate. As an example, there are the results of Sjogren et al (10) and conflicting findings of Peters and Wesselink (11).
There is an existing body of evidence concerning intentional replantation procedures that are primarily case reports or case series. However,
there are no related studies representing a level of evidence higher than
LOE 3 (12). Regenerative procedures will require outcome studies
characterized by a high level of evidence in order to determine the
procedures’ clinical applicability (13).
Subquestion #6 References
1. Strindberg LZ. The dependence of the results of pulp therapy on
certain factors. An analytic study based on radiographic and clinical
follow-up examination. Acta Odontol Scand 1956;14:21.
2. Fouad A, Burleson J. The effect of diabetes mellitus on
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3. Marending M, Peters OA, Zehnder M. Factors affecting the
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practice. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2005;99:119–24.
4. Ørstavik D, Qvist V, Stoltze K. A multivariate analysis of the
outcome of endodontic treatment. Eur J Oral Sci 2004;112:224–30.
1694
Rosenberg et al.
5. Zuolo ML, Ferreira MO, et al. Prognosis in periradicular
surgery: a clinical prospective study. Int Endod J 2000;33:91–8.
6. von Arx T, Jensen SS, Hanni S. Clinical and radiographic assessment of various predictors for healing outcome 1 year after periapical
surgery. J Endod 2007;33:123–8.
7. Farzaneh M, Abitol S, Lawrence HP, et al. Treatment outcome in
endodontics: The Toronto Study—phase II: Initial treatment. J Endod
2004;30:302–9.
8. Marquis VL, Dao TT, Farzaneh M, et al. Treatment outcomes in
endodontics: The Toronto Study—phase III: initial treatment. J Endod
2006;32:299–306.
9. Engstrom B, Hard AF, Segerstad L, et al. Correlation of positive
cultures with the prognosis for root canal treatment. Odontol Revy
1964;15:257–70.
10. Sjogren U, Figdor D, Persson S, et al. Influence of infection at
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with apical periodontitis. Int Endod J 1997;30:297–306
11. Peters LB, Wesselink PR. Periapical healing of endodontically
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12. Friedman S. Expected outcomes in the prevention and
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editors. Essential endodontology, 2nd ed. Ames, IA: Blackwell
2008:408 –69.
13. Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative
endodontics: a review of current status and a call for action. J Endod
2007;33:377–90.
JOE — Volume 35, Number 12, December 2009